Author Archives: John Post

About John Post

Othopedic Surgeon 6 Kona finishes Married, 3 children Marine Veteran Helicopter Pilot

PICKING THE PERFECT TRIATHLON SPORTS DOC by John Post, MD

Pick Picking The Perfect Triathlon Sports Doc

Bill Vollmar, MD
example of a perfect sports doc


“Son can you play me a melody, I’m not really sure how it
goes. But it’s sad and it’s sweet and I knew it complete when I wore
a younger man’s clothes.” Billy Joel

So you didn’t used get injured and now you might need to seek
medical help? The cover of the Triathlete Magazine a couple years ago,
various internet posts, etc. and the title of this article. These sources
gave a number of good suggestions. But most are neither written nor edited
by a physician and maybe another perspective could help.

Triathletes are what’s known in MBA circles as early adopters.
They’ll try things, seemingly anything (anything? Compression
socks…Biestmilch…dimpled aero wheels) often with minimal
proof/history that the new product/technique is actually beneficial,
but it might be. On the Slowtwitch site for example, when
one forum poster complains of a musculoskeletal problem, invariably one of the
“expert” responders notes the obvious need for ART (Active Release). Well,
ART can be very helpful in the right setting but the nearest practitioner to
my house according to the ART website is an hour and a half away!

The two photos above are of Bill Vollmar, MD, seemingly “only” a Family
Practitioner from Lancaster, PA and some would say might have
trouble spelling triathlon. But he is whip-saw smart, takes care of
almost exclusively athletes, and since unlike me he’s not a surgeon, would
likely have a non-surgical solution to almost any injury if it’s feasible.
Only as a last resort would he considerinvolving someone who might want to cut
on you! And, he is so good that he could take care of me and my entire family.
And lord knows I’ve had more than my share
of musculoskeletal problems – compartment syndrome, plantar faciitis, achilles
tendonitis, rotator cuff tear, I could on. The take home point is that, at least
for many of us, we don’t have to drive hours to the Pro from Dover with the
treadmill for a good portion of our medical needs, we just need to know what’s
available locally. In fact, like many locations, the go to guy here for most
running induced issues is the owner of the running shoe store. With 27 years of
seeing runners problems he could take care of the Olympic team! And I’ll bet
there are examples of this in your community, say the kids swim coach who’s
been working on swim strokes for decades.

So, as pointed out in Triathlete, Active.com, Beginner Tri, etc.
don’t be embarrassed to ask around to see what’s available, who’s available,
for your specific problem. Help could be right around the corner…and his/her
name might be Bill Vollmar

One more thing. Many of us have had something called Microfracture as part
or a knee arthroscopy. A recent article in Arthroscopy mmagazine notes a
study in which injecting stem cells as part of this procedure shows
significant promise in improving results.

Orthopedic surgeons are early adopters too!

John Post, MD
www.johnpostmdsblog.blogspot.com

DO YOU HAVE ANY SESAMOID BONES? by John Post, MD

Do
You Have Any Sesamoid Bones?

“Give me three steps, gimme three
steps mister…” Lynyrd Skynyrd

I was asked recently about an
athlete with a foot problem and a possible sesamoid fracture. It occurred to me
that most folks didn’t know they had sesamoid bones, or if they did, where they
were.

The simplest definition of a sesamoid bone is one that’s
surrounded by tendon or intratendinous. The most obvious example would
be the knee cap. This blog will be devoted to the pair of sesamoid bones
underneath the ball joint of the big toe. They are about the size of a lima
bean, normally glide front and back with each stride and rarely give us much
cause for concern. But as with any bone in the foot, they can be broken or
subject to a stress fracture. A true fracture takes a pretty significant injury
such as a fall from a height where we in the endurance sport world are more
likely to see a stress fracture from the usual causes. (See my two recent blogs
on this injury pattern.) The athlete with a true fracture is going to be
immobilized between 4 and 8 weeks, will be made non-weight bearing

on crutches, and like likely be doing all of his/her training in the pool
for a while.  Treating the stress fracture is much less aggressive, but
here, too, your running shoes will see no action for longer than you’d like.
Often times, sesamoid problems present as sesamoiditis, an inflammation
of the area caused by the usual culprits of too much too fast, especially
speed work or hills. One starts with the gradual onset of pain under the big
toe, initially present during only the hardest portion of the workout and
increasing to any running, even walking. There doesn’t seem to be much
redness or bruising. They can be slightly swollen but frequently it’s not
easy to see.

So what do you do?
Back off for a while. Maybe do a percentage of your weekly run volume in the
pool. (It can be fun.) Then, if you can unload the area of distress by using a
metatarsal pad or other device to very slightly overload the non-injured portion
of the foot being certain to ice down the area once the run is over. Don’t be so
aggressive that you risk frostbite but 15-20 minutes ought to do
it.

Lastly, trying to go through your log book examining each week, each
run, for clues as to the cause and how to never have it again is always
beneficial.  And if you’re successful, your “three steps” will be crossing the
finish line without pain!

John Post, MD

PATIENCE FOR IMPROVEMENT by John Post, MD

Here’s your Fearless Leader, Ben Greenfield, as he fits right in at the Kona Underpants Run this year.  Pretty sharp outfit there Ben, we can’t wait to see what 2012 looks like.

_______________________________________________________________

Patience For Improvement


Not everyone who comes to Kailua Bay
during Ironman race week wears a Speedo!

“I’d take any risk to tie back the hands of time.” Styx

I didn’t race
at IMH this year…and likely my body’s been sending messages loud and clear
that I’m done with iron distance racing. But on Sunday morning after the event,
I went for a bike ride and was astonished to see a couple runners. Pushing it!
At first I thought they were tourista like me but as I approached, I could see
that they both had Ironman wrist bands on and a race day sunburn on their neck
and shoulders from an especially hot day yesterday for the race. (There’s almost
no shade on the Big Island bike route. Maybe one could ride in the shade of an
overflying seagull…but that would present it’s own potential
hazard!)

Running? The day after IMH? What were they thinking? Were they
thinking? Maybe getting a jump start on training for their next iron distance
race…next weekend. Or, maybe they’re just not able to turn it
off.

Racing and training at this level causes significant breakdown
of bodily systems that need recuperation time be it from training or racing.
Although there are a select few who can get by with less…and these are the
ones we hear about in the press…most of have neither a red cape nor an “S” on
our chests. And Kryptonite doesn’t bother us one bit.

Why not take the
first several days after a race to let the soreness fade, blisters, if present
resolve, and only then begin a few low effort, short workouts focusing on form
and style, not quantity. Many would suggest that it be a full 10-14 days before
getting back into full training after a 140.6 effort, assuming you already have
a race scheduled. That time would be well spent on family activities, reading
(no, not about triathlon), maybe even go see the new Michael Jackson movie for
something completely different. Or, if you’re a guy, take your spouse to a chick
flick like “The Kings Speech.” I took my wife. And I liked it. Maybe it’s time to
simply be a husband and father/mother and wife, and not an athlete. Although no
one would fault you for drifting into thoughts about HED wheels during the
credits.

John Post, MD
This week we discuss Stem Cell Transplants

BLOOD CLOTS/BLOOD THINNERS by John Post, MD

 

Blood
Thinners and Blood Clots

Testing an athlete’s serum lactate
levels while pedaling under a controlled load and controlled conditions is one
way to determine the lactate threshold and from that one’s training zones. If
this athlete takes a blood thinner, would testing of this sort put him
or (and possibly as important in these litigious times) the
test director in jeopardy?

Blood is drawn from the athletes left ear
lobe at 3 minute intervals during testing.
_____________________________________________
Blood Clots/Thinners

I fail to be surprised each
time I see/hear about another athlete who’s taking blood thinner medication for
a recent, and some cases not so recent clot. There are frequent reports in a
number of the on line Tri forums and I thought a review would be beneficial.

A pulmonary embolism or clot in the lung (sometimes air or fat, etc.)
can be fatal! A person with an acute PE can complain of chest
pain, often worse with deep breathing, the onset of a cough which may contain
blood tinged sputum and they can breathe more rapidly. They may note both a
shortness of breath and more rapid heart rate. This is obviously an emergency –
go to the hospital – and treatment will be initiated to prevent new clots from
forming, start oxygen, and occasionally clot busting meds will be given. A
frequent source of clot can be the legs, say there’s been a long airline flight
(like to Kona), long car ride, etc. Other risk factors include birth control
pills, positive family history, recent orthopedic surgery, cancer, etc.
Prevention would obviously be the best choice as once diagnosed, there will
likely be a 3 – 6 month period where blood thinners are taken on a daily basis
and the blood is drawn at regular intervals to make sure the medication is
working correctly. It’s called Coumadin and is the active ingredient in rat
poison believe it or not.

To prevent a PE, when you are on a long
drive/flight get up and move around frequently, move your legs. Bed ridden
patients in the hospital can be fit with devices that squeeze the foot or calf
to keep the blood moving and prevent pooling.

Triathletes ask about
racing and training while taking Coumadin understanding that they are at
increased risk for bruising, bleeding -both external and internal – and that any
cut or abrasion on the skin will bleed more. Once the Coumadin dosage has
leveled off and the medical team feel the clot stabilized, then a return to
training can be considered. I don’t think anyone would take issue with swimming
or strength training, and probably not running if the return to the roads is
done slowly and carefully. Biking, where the potential for a crash (read injury)
is higher, gives us the biggest worry. All of us have crashed at one point or
another and in one of my previous blogs I reported being momentarily unconscious
after my helmet contacted the asphalt unexpectedly. I am very glad I wasn’t
Coumadinized when that happened because of the risk of bleeding into my head and
permanent damage. I believe I’d be inclined to ride the stationery bike watching
old TdF videos for quite some time.

Lastly, the question of eating green,
leafy vegetables comes up as they have plenty of vitamin K and vitamin K
reverses the blood thinning action. Most people would agree that if your diet is
constant, eating about the same amount of greens daily, that you should be ok
and it’s those patients who have a big salad one day (the day prior to their
blood test could be a problem) but chili cheese dogs on the the other days. Keep
it even.

In short, prevent those leg clots by moving around on long trips
and, if for any reason you think you might have a PE, get to the hospital
pronto, it’s the best course for you.

www.johnpostmdsblog.blogspot.com

POOL RUNNING CAN BE FUN by John Post, MD

Pool
Running Can Be Fun



“You got to do what you can, and let Mother Nature do the rest.”

Meat Loaf

At some time in our careers, water running, or aqua jogging,
will be recommended as a method of cross training injured athletes. Others find
it an ideal form of non-impact aerobic training. Basically, you
“run” in water that’s deeper than your limb length. This can extend from the
diving well up in to the lanes, with a flotation vest or belt to increase
buoyancy…so you don’t drown. Although most run the length of the available
area, others attach themselves, say to the ladder, and run in place. Running
with a partner provides easy conversation, or, a water proof source of music
may be of benefit. One attempts to mimic one’s form as closely as
possible to that used on land.

Mimicking run duration and intensity is also important. For
example, if you’re scheduled for 45 minutes of steady running, do 45 minutes in
the water. As you’d imagine, heart rates will be lower but many find that they
can come within about 10-15 beats/minute of their land running HR. It’s possible
to run intervals repeating levels of intensity done on land.

Athletes have shown that not only can they maintain their level of
fitness, but with dedication can actually improve. This comes into play
when one begins to return to the road. Initially, shorter workouts can
be supplemented with time in the water keeping the workout time “whole.”

Again, it’s a priority to duplicate your form on land, arm swing, head
position, elbow engagement, etc. If your pool has both vests and belts,
you may find one or the other allows you to more easily maintain this action.
Your hip flexion will likely increase in the pool giving you an artificially
lengthened “stride.”

Like many, I am currently water running at the end of my swim workout. And,
watching the others in my swim group continue to turn out the yards is all
the distraction I need to stay focused. And, I can still joke with the
lifeguards while I’m running!”

STRESS FRACTURE, EH? PART TWO by John Post, MD

Stress
Fracture, Eh? Part Two

This is Ironman Week here in Kona as the sleepy fishing village and
occasional port for cruise ships turns into Triathlon Central. There are
people everywhere, fit people, running and biking up and down Alii Drive.
I hadn’t been here an hour before seeing Norman Stadler and Chrissie
Wellington. Good luck to them both on Saturday! It’s going to be a
fun week.

“Dig Me” Beach, a term I heard
credited to Scott Tinley, is seen here, soon to be clogged with
swimmers trying to get used to the change from simply following the
line on the bottom of the pool to the gentle waves and salt water of
the Pacific in Kailua Bay.

But the athlete with an injury like a stress fracture is
sitting home, an opportunity missed. I covered the basics of stress fractures
here 1/15. That these are in the category of overuse injuries where the
muscular envelope of the lower extremity becomes fatigued and the skeleton
is unable to adapt to the increased load.

The bone fractures as it is unprepared for the intensity of exercise delivered.
This might be advancing one’s training program
too quickly, changing from the relative forgiveness of the running track to
asphalt or concrete, aged or improper equipment or increasing exercise duration
as a tennis player with a substantial increase in court time.

There are 26 bones in the foot and most likely all of them have been subject
to a stress fracture at one time or another. They are frequently seen in the
other bones of the lower extremity when insufficient rest is included between
workouts. People taking Prednisone, Dilantin and other medications are at
increased risk. Women have more than men.

The predisposing symptom is pain, not so much at
rest, but brought on by exercise and it worsens. Although occasionally
visible as a crack in the bone on x-ray, frequently these films will be
negative. If the examiner finds point tenderness over a bone and a stress
fracture is suspected, an advanced study like an MRI, or more likely a bone
scan, will be order. (This is not to be confused with the DXA, the bone scan
used to measure osteoporosis, predominantly in women.)

If diagnosed, the order of the day will be rest.
This can be up to 6-8 weeks, some will be placed on crutches or given a fracture
boot, but if one returns to sport before it heals, chronic difficulties can
follow making healing a challenge. Triathletes might be shifted to pool running
and biking so as not to lose excessive fitness.

So, if you have recurring pain in the same location, and think this may
potentially describe you, get it checked out, you’ll be glad you did.

John Post, MD Kona Resident 10/1-9
www.johnpostmdsblog.blogspot.com

FIRE CRACKERS THROWN AT CYCLIST by John Post, MD


Yes, they have Halloween, even in Kona, Hawaii. This home is on Alii Drive. Note palms in the back ground.

Those of you who read my blog know that it’s all about exercise safety in addition to caring for the injured athlete. One of our better local triathletes was beginning a ride near his home last week when a slow moving minivan approached with the sliding side door open. At first the biker heard explosions to his right and then very quickly he felt fire crackers hit his shoulder and neck! As the driver sped away, the athlete took chase. But who can catch a car on their bike?

Unfortunately for this driver, he passed the athletes wife in her car at the next stop sign where a quick cell phone call from our boy allowed her to follow the van getting the license # and a description of the driver. He was apprehended that evening and a confession quickly followed. Charges have been pressed against the 11th grader from a nearby high school, and since he’s under 18 and this is his first offense, he’ll avoid court and go straight to the probation officer. As the athlete noted, “I make my living as a pilot and can’t afford to lose my hearing or eyesight.”

Our athlete was uninjured, although I suspect many of us – me included – would have crashed or run into a phone pole if the firecrackers were thrown at us. I believe I might think some one was trying to kill me. So what do we learn from this? Always carry your cell phone. Get in the habit of looking at license plates, even jot them down, which is easy to do if you keep pen and paper in your fanny pack with your emergency first aid kit. Don’t confront rude drivers alone.

It’s easy to think about retribution, about getting even, about finding those who run us off the road and putting a potato in their exhaust at night or flattening the tires on their car…or worse! But our goal is to live to ride another day and some of those folks on the road where I live might be just crazy enough to run me into the weeds if they thought I’d done something to them. Or worse, they’d run you into the weeds for something I did. And then we’d all lose.

Be careful………….. it’s a jungle out there.

THE MENISCUS; TORN YOURS? by John Post, MD

The
Meniscus – Torn Yours?


”
I don’t need a whole lots of
money, I don’t need a big, fine car. I got everything that a man could want, I
got more than I could ask for.”
Grand Funk

In other
words, my knees work just fine, thank you.

The meniscus is an
important structure in your knee. Menisci, actually as we have two in each knee,
an inside (medial) one and an outside (lateral) one. They are “C” shaped bits of
fibrocartilage also known as semi-lunar cartilages which serve many functions.
This is important as it wasn’t that many years ago that surgeons felt the
meniscus to have no purpose and excised them at will, especially in the
pre-arthroscopy days. Some of you no doubt can remember that HS athletic injury
by looking at the sizable scar on your knee from your open menisectomy
(excision).

It’s currently felt that the meniscus aids in the lubrication
of the joint, stress transfer from femur to tibia, and that it contributes to
the stability of the knee. Unless injured, the meniscus will provide a lifetime
of service to it’s owner with out complaint. That said, through injury,
arthritis or just plain bad luck, any among us may suffer a “torn knee
cartilage.” As was true for both Tom Brady and Tiger Woods, the tear can
accompany injury to one or more major ligaments. Usually bad news.

Frequently, the injured triathlete will have a physical exam, x-rays
and/or an MRI with subsequent arthroscopy to remove or repair the damaged
meniscus. (In highly selected cases, a meniscus transplant may be considered
when more traditional methods have failed.) The arthroscopy is done in the
sterile environment of the operating room under a variety of types of anesthesia
– most of my patients watched theirs on the TV at bedside! The scope is
introduced through two 1/4″ punctures which rarely even need stitches at the
end. Oftentimes the procedure is completed in under an hour, there are no
crutches, and rehab exercises begin in the recovery room.

The surgeon
who’s seen the inside of your knee is likely in the best position to determine
your return to sport, possible limitations, etc.

Take good care of your
menisci, they should last a while!

John Post, MD
Image 1 from Google images

CARRYING ID ON YOUR BIKE by John Post, MD

Plea For Carrying ID When You Ride


I’ve written before about the need to have some form of rapid ID on you when
you’re biking.  Sadly, this article makes that point.
________Bicyclist Killed By Car ID’d

Father Of James Madison University Frosh Was On Way To Surprise Son

By Pete DeLea and Jeremy Hunt

HARRISONBURG –
Joseph V. Mirenda left Wintergreen on his bicycle Tuesday morning bound for
Harrisonburg. He was going to stop by and surprise his son, a freshman at
James Madison University, but Mirenda didn’t make it to the end of the 50-mile
trek. On Wednesday, police identified Mirenda, 49, of Virginia Beach, as
the victim in Tuesday’s fatal crash in Rockingham County.

Around 10:30 a.m. Tuesday, emergency personnel were dispatched to Port Republic Road,
about a mile east of Cross Keys Road, where they found the cyclist lying in the
ditch.   Mirenda was riding west on Port Republic Road when he was struck
by a westbound 2000 Ford Taurus driven by Jessica Chandler, according to the
Virginia State Police.

No charges were filed as of press time Wednesday,
but investigators obtained a search warrant for the driver’s cell phone
records. First Sgt. Bryan Hutcheson with the state police said
investigators will be looking into whether Chandler, 22, of Port Republic, was
talking on her cell phone or texting in the moments before the crash
occurred.

“We don’t want to leave any stones unturned,” Hutcheson said.

Although the Daily-News Record has confirmed a search warrant was
issued in the case, the document remains sealed by court order at the Rockingham
County Circuit Court. Meanwhile, investigators are still trying to piece
together exactly how the crash happened.

They had spent Tuesday and most
of Wednesday trying to determine the name of the cyclist, who had no
identification on him.

State police caught a break in the investigation Wednesday afternoon when they
received a call from the Wintergreen Police Department.

A Virginia Beach woman contacted the department and said she
couldn’t reach her husband, who was staying at the family’s home in Wintergreen,
Hutcheson explained.

The wife mentioned he may have gone on a bicycle ride.

Wintergreen officers recalled seeing a man riding a bicycle there
Tuesday morning, and he matched the description of the then-unidentified cyclist
killed in Tuesday’s crash.

The state police and Wintergreen officers then
confirmed the man’s identity based on an inscription on a wedding band he was
wearing.

It said “Frauke & Joe” with the date 9-24-88 on
it.

Contact Pete DeLea at 574-6278 or
pdelea@dnronline.com
______________________________________________________

When
I put this up on one of the Tri web site forums, I received a number of cleaver
answers where some people carry there drivers license, a business card, their
cell phone, etc. One athlete has all his vitals written inside his helmet. But
is seems that many simply have identifying data on a card in a plastic bag in a
fanny pack, bike saddle tool kit, etc. Please make the effort. Do it today!

 

John Post, MD
www.johnpostmdsblog.blogspot.com

WHEN 2ND IS BETTER THAN 1ST by John Post, MD

Setting Goals – When 2nd is Better Than 1st

This
is Sarah Reinertsen, the only female amputee finisher of the Hawaiian
Ironman. Born with a limb deficiency known as PFFD, She had an above
the knee amputation a very early age and never really knew life
without a prosthesis. Seen here from the back during the 2007 Kona
Underpants Run (in a snappy home made skirt of old GU wrappers),
her goal was the 2004 IMH. But, she fell short on the bike missing
the cut off. Undaunted, she made some changes during the year returning
in 2005. She bettered her bike split by two hours and finished the race
easily with a big smile on her face. You talk about goal oriented!”

 

Another athlete I know is pretty competitive in his age group. In fact he can
frequently win the age group at local races.

Ben Greenfield teaches that when you set your expectations for an upcoming
race, you need to do so carefully by picking an outcome that’s dependent on your
behavior alone. For example, a goal of winning
the age group depends on the potential for a perfect race for you and the luck
that nobody who can beat you shows up! Maybe, rather than an outcome of age
group victory, the choice of a PR run split, or finally winning both T1
and T2 would be reasonable. A result that is both within your reach
based on past performance and one that is almost totally under your
control.

Our athlete has been thinking all summer that he would be
getting yet another age group win at the upcoming tri (yawn – more hardware!)
But what he didn’t count on was that the race would be late in filling and that
although he’d periodically reviewed the list of entrants assuring himself that
he was king cheese, at the last minute, someone from out of town registered who was way out
of our boy’s league.

Initially a little put out (and briefly considering,
“Why even go if I can’t win?”) he eventually saw the race as an opportunity to
really push it from the minute he got out of the water to the minute he exited
T2 on the run. This change in attitude resulted in a terrific race, even though
he got 2nd place by a wide margin, he managed a faster swim, faster T1,
faster bike, faster T2, and faster run than the previous year. Overall, he cut
his time for the sprint tri by SEVEN minutes!

And guess who had a huge grin getting that 2nd place trophy!

John Post, MD
www.johnpostmdsblog.blogspot.com
Triathletes with Joint Replacements